Intrauterine Substance Exposure Research Articles

Pediatric Hospital Admissions with Concern for Neglect: Correlations Between Neglect Types and Other Clinical and Environmental Risk Factors.

Child neglect is a public health concern with negative consequences that impact children, families, and society. While neglect is involved with many pediatric hospitalizations, few studies explore characteristics associated with neglect types, social needs, and post-discharge care. Data on neglect type, sociodemographics, social needs, inpatient consultations, and post-discharge care were collected from the electronic medical record for children aged 0-5years who were hospitalized with concern for neglect during 2016-2020. Frequencies and percentages were calculated to determine sample characteristics. The Chi-square Test for Independence was used to evaluate associations between neglect type and other variables. The most common neglect types were inadequate nutrition (40%), inability to provide basic care (37%), intrauterine substance exposure (25%), combined types (23%), and inadequate medical care (10%). Common characteristics among neglect types included age less than 1year, male sex, Hispanic ethnicity, public insurance, past involvement with Child Protective Services, and inpatient consultation services (social work, physical therapy, and occupational therapy), and post-discharge recommendations (primary care, physical therapy, and regional center). Neglect type groups varied by child medical history, social needs, and discharge recommendations. Statistically significant associations supported differences per neglect type. Our findings highlight five specific types of neglect seen in an impoverished and ethnically diverse geographic region. Post-discharge care needs should focus on removing social barriers and optimizing resources, in particular mental health, to mitigate the risk of continued neglect. Future studies should focus on prevention strategies, tailored interventions, and improved resource allocations per neglect type and discharge location.

Changing the Lens on How We View Mothers of Neonates with Intrauterine Substance Exposure.

Changing the Lens on How We View Mothers of Neonates with Intrauterine Substance Exposure.

Elucidating the Relationship Between Maternal Diabetes and Neonatal Abstinence Syndrome: A 2017-2018 Project WATCH Study in Rural Appalachia.

Previous research indicated that diabetes during pregnancy results in a more permeable placenta. Based on this data, we hypothesized that women with maternal diabetes were more likely to have infants who developed neonatal abstinence syndrome (NAS). The purpose of the study was to examine the association between maternal diabetes and NAS in a cohort of women reporting substance use during pregnancy. This study used data from a population-based cohort of all newborns born in 2017 and 2018 (N = 36,974) in the state of West Virginia and restricted the analysis to those infants with intrauterine substance exposure (14%, n = 5188). Multiple logistic regression was performed to analyze the adjusted relationship between maternal diabetes and NAS while controlling for maternal and infant covariates. Just over 28% of women with diabetes had an infant who developed NAS, whereas 34.8% of women without diabetes had an infant who developed NAS. The adjusted odds ratio of infants developing NAS born to women with diabetes was 0.70 (95% confidence interval: 0.51, 0.94) compared with those born to mothers without diabetes after controlling for covariates. Contrary to our hypothesis, the study suggests that maternal diabetes during pregnancy is associated with a decreased risk of an infant developing NAS. Future research generating from this hypothesis may lead to potential implications for practice for infants born to mothers with substance use during pregnancy and diabetes. More research should be conducted to investigate the relationship between glucose metabolism and NAS.

Abstract P236: Breastfeeding and Drug Free Moms and Babies Project: Comparing Rates in a Rural Appalachia Project to Project Watch to Support Healthy Baby Outcomes

Breastfeeding is linked to improved cardiovascular health for both child and mother; however, many hospitals do not encourage or provide support for breastfeeding while either in the hospital or after delivery. This is particular true of mothers with substance use disorder (SUD) more generally or with opioid use disorder (OUD) more specifically. The Drug-Free Moms and Babies Project (DFMB) program was designed to develop and evaluate programs that provide treatment and recovery services for pregnant and postpartum women with SUD; data is now available for 2018 and up to October 2019. Project WATCH collects data on all births in West Virginia (WV) and includes questions about breastfeeding intent and actual breastfeeding practices. A special focus for both programs includes encouraging or assessing breastfeeding in WV, which ranked 46 th in the nation for ever breastfeeding in 2015. There were 688 pregnant women in DFMB 2018-2019 with information on breastfeeding intent; at program entry, 54.8% intended to breastfeed. Relative to all births in WV in 2018 (Project WATCH data; N=18177), 57.4% intended to exclusively breastfeed. Among all births with intrauterine substance exposure (IUSE) in 2018 (N=2558), 31% intended to exclusively breastfeed. Of the 688 in the DFMB program, 528 completed the program through delivery and had breastfeeding information. Of those, 225 (42.6%) actually breastfed after birth, and 80.6% were given the opportunity to breastfeed before leaving the hospital. For actual breastfeeding rates among all births in WV (Project WATCH), 37.4% exclusively breastfed before hospital discharge, and among births with IUSE, 32.0% exclusively breastfed. We also examined breastfeeding rates among those infants born with NAS in the DFMB program (N=220, 42.8%). Of these women, 49.7% intended to breastfeed, 37.4% breastfed after birth, and 73.5% were given the opportunity to breastfeed before hospital discharge. Among all 2018 WV NAS births (N=901), actual breastfeeding rate was 9.1%. Results suggest DFMB programs improve breastfeeding rates when compared against all births in the state, and among births with IUSE. The program continues to intervene with this high-risk group to improve breastfeeding rates, which we believe will later impact cardiovascular health for both mothers and babies.

Abstract P387: Risk Factors for Neonatal Intensive Care Unit Admission; Project Watch, 2012-2017

Background: Neonatal intensive care unit (NICU) admission is often due to specific cardiovascular conditions. Low birthweight, another common reason for NICU admission, is also linked to later cardiovascular risk. Within the past decade, the rate of NICU admissions in the United States has significantly increased. Identification of emerging risk factors for NICU admission will help inform efforts to reduce the number of newborns requiring intensive care. Methods: The objective of this study was to identify risk factors for NICU admission in all infants born in West Virginia (WV), 2012-2017, via Project WATCH. Fifteen exposure variables including demographics, maternal and infant characteristics, were included in multivariable logistic regression analyses, stratified by preterm and term births. Results: Of 120,894 neonates, 6,393 (5.3%) were admitted to NICU. Among preterm infants (Table 1), predictors included male sex (OR: 1.11), insurance status (OR: 1.29), APGAR scores less than or equal to 3 (OR: 2.57), maternal diabetes (OR: 1.68 and 2.01), residence outside WV (OR: 1.27), intrauterine substance exposure (OR: 1.94), congenital abnormalities (OR: 2.58), and low birthweight (OR: 1.73 and 6.64). Risk factors in term infants included all factors identified for preterm infants, as well as maternal smoking, maternal age, and number of previous pregnancies. Conclusions: In addition to infant characteristics predictive of NICU admission (e.g., birthweight and APGAR score), socioeconomic factors (e.g., insurance status and rurality) and preventable risk factors (e.g., maternal smoking and substance use) provide an opportunity for intervention during pregnancy, with the goal to decrease the number of newborns requiring intensive care.

Intrauterine Substance Exposure and the Risk for Subsequent Physical Abuse Hospitalizations.

To describe the relative risk for a physical abuse hospitalization among substance exposed infants (SEI) with and without neonatal abstinence syndrome (NAS). We created a nationally representative US birth cohort using the 2013 and 2014 Nationwide Readmissions Databases. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify newborns, predictor variables, and subsequent hospitalizations for physical abuse within 6 months of discharge from newborns' birth hospitalization. Predictor variables included newborn demographics, prematurity or low birth weight, and intrauterine substance exposure: non-SEI, SEI without NAS, and SEI with NAS. Multiple logistic regression calculated adjusted relative risks and 95% confidence intervals. A subanalysis of newborns with narcotic exposure was performed. There were 3,740,582 newborns in the cohort; of which 13,024 (0.4%) were SEI without NAS and 20,196 (0.5%) SEI with NAS. Overall, 1247 (0.03%) newborns were subsequently hospitalized for physical abuse within 6 months. Compared to non-SEI, SEI with NAS (adjusted relative risks: 3.84 [95% confidence intervals: 2.79-5.28]) were at increased risk for having a subsequent hospitalization for physical abuse, but SEI without NAS were not. A similar pattern was observed among narcotic-exposed infants; infants with NAS due to narcotics were at increased risk, but narcotic-exposed infants without NAS were not. Our results suggest that newborns diagnosed with NAS are at increased risk of physical abuse during early infancy, above that of substance-exposed infants without NAS. These results should improve the identification of higher-risk infants who may benefit from more rigorous safety planning and follow-up care.

Testing the programming of temperament and psychopathology in two independent samples of children with prenatal substance exposure.

Prenatal programming models have rarely been applied to research on children with prenatal substance exposure, despite evidence suggesting that prenatal drug exposure is a form of stress that impacts neurodevelopmental outcomes and risk for psychopathology. Utilizing data from two longitudinal multisite studies comprising children prenatally exposed to substances as well as a nonexposed comparison group (Maternal Lifestyle Study, n = 1,388; Infant Development, Environment, and Lifestyle study, n = 412), we tested whether early phenotypic indicators of hypothesized programming effects, indexed by growth parameters at birth and infant temperament, served as a link between prenatal substance exposure and internalizing and externalizing behavior at age 5. Latent profile analysis indicated that individual differences in reactivity and regulation for infants prenatally exposed to substances was best characterized by four temperament profiles. These profiles were virtually identical across two independent samples, and demonstrated unique associations with adjustment difficulties nearly 5 years later. Results of path analysis using structural equation modeling also showed that increased prenatal substance exposure was linked to poorer growth parameters at birth, profiles of temperamental reactivity in infancy, and internalizing and externalizing behavior at age 5. This pathway was partially replicated across samples. This study was among the first to link known individual-level correlates of prenatal substance exposure into a specific pathway to childhood problem behavior. Implications for the developmental origins of a child's susceptibility to psychopathology as a result of intrauterine substance exposure are discussed.

Intrauterine exposure to tobacco and executive functioning in high school

BackgroundExecutive functioning (EF), an umbrella construct encompassing gradual maturation of cognitive organization/management processes, is important to success in multiple settings including high school. Intrauterine tobacco exposure (IUTE) correlates with negative cognitive/behavioral outcomes, but little is known about its association with adolescent EF and information from real-life contexts is sparse. We evaluated the impact of IUTE on teacher-reported observations of EF in urban high school students controlling for covariates including other intrauterine and adolescent substance exposures. MethodsA prospective low-income birth cohort (51% male; 89% African American/Caribbean) was followed through late adolescence (16–18 years old). At birth, intrauterine exposures to cocaine and other substances (52% cocaine, 52% tobacco, 26% marijuana, 26% alcohol) were identified by meconium and/or urine assays, and/or maternal self-report. High school teachers knowledgeable about the student and unaware of study aims were asked to complete the Behavior Rating Inventory of Executive Functioning-Teacher Form (BRIEF-TF) annually. ResultsTeachers completed at least one BRIEF-TF for 131 adolescents. Multivariable analyses included controls for: demographics; intrauterine cocaine, marijuana, and alcohol exposures; early childhood exposures to lead; and violence exposure from school-age to adolescence. IUTE was associated with less optimal BRIEF-TF Behavioral Regulation scores (p <0.05). Other intrauterine substance exposures did not predict less optimal BRIEF-TF scores, nor did exposures to violence, lead, nor adolescents’ own substance use. ConclusionsIUTE is associated with offspring’s less optimal EF. Prenatal counseling should emphasize abstinence from tobacco, as well as alcohol and illegal substances.

Effects of intrauterine substance and postnatal violence exposure on aggression in children

During the cocaine epidemic of the 1980s and early 1990s, many expressed fears that children with intrauterine cocaine exposure (IUCE) would grow up to be unusually violent. The present study examines the relationship of caregiver reports of school-age children's aggressive behavior with IUCE and postnatal exposure to violence. Respondents were 140 low-income, primarily African American children, ages 8-11, and each child's current primary caregiver from a longitudinal study evaluating potential long term sequelae of IUCE. Multiple regression analyses were used to investigate the independent and interactive effects of level of IUCE (None (n = 69), Lighter (n = 47), Heavier (n = 24)) and exposure to violence (Violence Exposure Scale for Children-Revised) on aggressive behavior (Child Behavior Checklist), while also controlling for other intrauterine substance exposures and additional contextual factors. Children's self-reported exposure to violence was significantly positively associated with caregivers' reports of aggressive behavior (β = 2.17, P = .05), as was concurrent caregiver's psychiatric distress (β = .15, P = .003). However, neither IUCE nor its interaction with exposure to violence showed a significant association with aggressive behavior. Findings suggest the importance of postnatal social environment rather than IUCE in predicting aggressive behavior in childhood.

Psychological Distress Among School-Aged Children with and Without Intrauterine Cocaine Exposure: Perinatal Versus Contextual Effects.

Whether intrauterine cocaine exposure (IUCE) explains unique variance in psychiatric functioning among school age children, even after controlling for other biological and social risk factors, has not been fully delineated. As part of a longitudinal birth cohort study of children with and without IUCE, we conducted and analyzed data based on structured clinical interviews with 105 children (57% male) and their caregivers when the child was approximately 8.5 years old; 47% of the children had experienced IUCE. Interviews included past and current major psychological disorders and sub-threshold mental health symptoms. Potential covariates were ascertained by interviews of birth mothers and other caregivers from shortly after the child's birth until the 8.5-year visit. More than one-third of children met DSM-IV criteria for one or more mood, anxiety, attention deficit, or disruptive behavior disorders. IUCE was not significantly associated with children's history of psychological distress, in either bivariate or multiple logistic regressions. In contrast, birth mothers' acknowledgement of greater psychiatric distress at baseline and higher levels of alcohol consumption during pregnancy, and at 8.5 years caregivers' reports of their own psychological distress, and children's lower IQ were predictors of higher rates of psychological morbidity. Findings are consistent with prior reports suggesting that, regardless of IUCE status, children from low-income, urban backgrounds are at heightened risk for psychological distress. Results underscore the need for closer monitoring of the mental health of children living in low-income households, with or without intrauterine substance exposures, to facilitate access to appropriate services.

Prenatal substance exposure: What predicts behavioral resilience by early adolescence?

Understanding behavioral resilience among at-risk adolescents may guide public policy decisions and future programs. We examined factors predicting behavioral resilience following intrauterine substance exposure in a prospective longitudinal birth-cohort study of 136 early adolescents (ages 12.4-15.9 years) at risk for poor behavioral outcomes. We defined behavioral resilience as a composite measure of lack of early substance use initiation (before age 14), lack of risky sexual behavior, or lack of delinquency. Intrauterine substance exposures included in this analysis were cocaine, tobacco, alcohol, and marijuana. We recruited participants from Boston Medical Center as mother-infant dyads between 1990 and 1993. The majority of the sample was African American/Caribbean (88%) and 49% female. In bivariate analyses, none and lower intrauterine cocaine exposure level predicted resilience compared with higher cocaine exposure, but this effect was not found in an adjusted model. Instead, strict caregiver supervision (adjusted odds ratio [AOR] = 6.02, 95% confidence interval (CI) [1.90, 19.00], p = .002), lower violence exposure (AOR = 4.07, 95% CI [1.77, 9.38], p < .001), and absence of intrauterine tobacco exposure (AOR = 3.71, 95% CI [1.28, 10.74], p = .02) predicted behavioral resilience. In conclusion, caregiver supervision in early adolescence, lower violence exposure in childhood, and lack of intrauterine tobacco exposure predicted behavioral resilience among a cohort of early adolescents with significant social and environmental risk. Future interventions should work to enhance parental supervision as a way to mitigate the effects of adversity on high-risk groups of adolescents. (PsycINFO Database Record

Intrauterine substance exposures and Wechsler Individual Achievement Test-II scores at 11 years of age

The goal of this study was to evaluate whether intrauterine exposure to cocaine, alcohol, tobacco, or marijuana was associated with unique variance in children's academic achievement test scores after controlling for other substance exposures and contextual variables. Academic achievement scores (Wechsler Individual Achievement Test-Second Edition (WIAT-II)) were collected from 119, low-income, urban 11-year-olds enrolled in a prospective longitudinal study of intrauterine cocaine exposure (IUCE). Newborn recruitment eligibility included >36 weeks gestational age, no neonatal intensive care, no intrauterine exposure to illicit drugs except cocaine or marijuana, and no evidence of fetal alcohol syndrome (FAS). Intrauterine substance exposures (cocaine, marijuana, alcohol, tobacco) were documented in the newborn period using biological assays and maternal self-report. Multivariate analyses evaluated the relationship of each intrauterine exposure and each WIAT-II score controlling for contextual variables and the other substance exposures. In secondary analyses, the Child Depression Inventory (CDI) was added to final models. Results indicate that neither IUCE nor intrauterine exposure to marijuana or tobacco was associated with lower WIAT-II scores in multivariable analyses. Intrauterine alcohol exposure predicted significant variance in Math Reasoning and Spelling scores, but inclusion of children's depressive symptoms attenuated the relationship. Lower maternal education and maternal US birth were also associated with lower WIAT-II scores. Our analyses indicate that among low-income, urban 11-year-olds without a diagnosis of FAS, intrauterine alcohol exposure was negatively associated with math and spelling achievement scores after controlling for other intrauterine substance exposures and contextual factors. That relationship in this sample was partially mediated by children's depressive symptoms, but we cannot establish whether these lower achievement scores precede or follow depressive symptoms. Our findings highlight that neurobehavioral studies evaluating a primary potential neuroteratogen should evaluate other associated intrauterine exposures and contextual factors.

Mental preparation during pregnancy in women with substance addiction: a qualitative interview‐study

ABSTRACTThe interplay between pregnancy and addiction is usually studied quantitatively, and the focus is often on the adverse effects of intrauterine substance exposure. This study explores the perspective of the mothers‐to‐be by examining the subjective experience of pregnancy in substance‐addicted women. Fourteen women in family treatment for substance use disorder participated in eight focus groups. The data were analysed according to interpretative phenomenological analysis. The findings show that recognition of pregnancy was distorted and delayed, and strong feelings of ambivalence and guilt persisted throughout pregnancy, along with hope for change. Addiction and an intense preoccupation with external expectations are seen as a threat to intrauterine attachment and mental preparation for the caregiving role. Interventions must take into account the specific ways in which addiction influences the psychological processes of pregnancy; specifically, providing adequate social support and security should be considered.

Early adolescent executive functioning, intrauterine exposures and own drug use

Individual differences in adolescents' executive functioning are often attributed either to intrauterine substance exposure or to adolescents' own substance use, but both predictors typically have not been evaluated simultaneously in the same study. This prospective study evaluated whether intrauterine drug exposures, the adolescents' own substance use, and/or their potential interactions are related to poorer executive functioning after controlling for important contextual variables. Analyses were based on data collected on a sample of 137 predominantly African-American/African Caribbean adolescents from low-income urban backgrounds who were followed since their term birth. Intrauterine substance exposures (cocaine, marijuana, alcohol, and cigarettes) and adolescents' substance use were documented using a combination of biological assays and maternal and adolescent self-report. At 12–14 years of age, examiners masked to intrauterine exposures and current substance use assessed the adolescents using the Delis–Kaplan Executive Function System (D-KEFS), an age-referenced instrument evaluating multiple dimensions of executive functioning (EF). Results of covariate-controlled analyses in this study suggest that when intrauterine substance exposures and young adolescents' substance use variables were in the same analysis models, subtle differences in specific EF outcomes were identifiable in this non-referred sample. While further study with larger samples is indicated, these findings suggest that 1) research on adolescent substance use and intrauterine exposure research should evaluate both predictors simultaneously, 2) subtle neurocognitive effects associated with specific intrauterine drug exposures can be identified during early adolescence, and 3) intrauterine substance exposure effects may differ from those associated with adolescents' own drug use.

Infants of Drug-dependent Mothers

1. Lauren M. Jansson, MD* 2. Martha L. Velez, MD* 1. *Department of Pediatrics, The Center for Addiction and Pregnancy, The Johns Hopkins University School of Medicine, Baltimore, MD. After completing this article, readers should be able to: 1. Recognize the effects of maternal substance use on the developing fetus, neonate, and growing child. 2. Describe the effect of maternal substance use on the mother-infant dyad. 3. Discuss the factors that may serve as mediators and moderators of the effects of maternal substance use on the child. 4. Understand the complex context within which the substance-abusing mother and her infant must be considered. 5. Evaluate and manage the substance-exposed dyad. In utero substance exposure continues to pose a public health and societal dilemma. Prenatal exposure to legal and illegal substances is a substantial and preventable risk factor for developmental alterations in infants. Intrauterine substance exposure affects more newborns than many other common major medical conditions, making the problem of the substance-exposed infant an inevitable concern for all pediatricians. Of the 4.3 million infants born annually in the United States, between 800,000 and 1 million are born to women who used drugs during pregnancy; approximately 1 in 9 infants is exposed to alcohol, 1 in 5 is exposed to nicotine, and 1 in 20 is exposed to illegal drugs. Opioid use during pregnancy is a growing concern due to the rise in abuse of prescription opioids (eg, hydrocodone, oxycodone) in women of childbearing age. Currently, 5.4 million children live with a parent who has a substance use disorder, and 3.4 million live with a mother who has a substance use disorder in the United States. (1) Resumption of drug use following childbirth is an additional concern; in a recent report, cigarette, alcohol, binge alcohol, and marijuana use rates were higher in women with a child …

Developmental Outcome in Children with Intrauterine Exposure to Substances

The developmental outcome of children born to Swiss substance-dependent mothers in a residential treatment program was studied in a sample of 61 children ranging from infancy to preadolescence (mean age = 5.10, SD = 3.10 years) by use of age-appropriate tests of intelligence. A large list of biological and psychosocial risk factors was tested for associations with outcome in the children. The mean profile of test findings across all age ranges was significantly lower than population norms and there was an excess of children with subnormal intellectual functioning. Performance IQ was associated negatively only with intrauterine substance exposure, but with none of the other risk factors. Among the various substances, predominantly heroin or methadone were responsible for this association when controls for nicotine or cannabis consumption were made. The study provides further evidence that intrauterine exposure to heroin and methadone negatively affects the developmental outcome in the offspring of substance-dependent mothers.

Drag Exposed Children and the Foster Care System: In the Best Interests of the Child?

ABSTRACT Children born to substance abusing women face many risks that can impede optimal developmental outcome. These risks include both potential neurologic and organic sequelae of intrauterine substance exposure, as well as additional risk factors in their postnatal environment. Foster care placement is a common occurrence among this population. The current study was conducted to explore the developmental status of a group of drug exposed infants and toddlers in foster care. Twenty-seven children placed through a church-based foster care program were observed. All but one of the children were African-American and nearly half (48%) had been placed shortly after birth. The children ranged in age from 1 to 29 months. Home environment and caregiver-child interaction was assessed using the HOME Inventory and the NCAS Feeding and Teaching Scales. Children were also given physical, neurological, and developmental assessments (Mean age = 11.7 months). While the majority of the children fell within normal limits on developmental testing, 28% were considered at risk for cognitive delay and over half exhibited suspect or abnormal neurological signs. Many were felt to be at further risk because of poor home environment and/or caregiving. Implications for intervention and policy changes are discussed.

Three-Year Outcome of Children Exposed Prenatally to Drugs

To evaluate the 3-year behavioral and developmental outcome of children prenatally exposed to maternal substances of abuse. Ninety-three children exposed prenatally to cocaine and other drugs taken by the mother during pregnancy (Group 1), 24 polydrug/noncocaine exposed children (Group 2), and 25 nonexposed children (Group 3) were evaluated at 3 years of age as part of a longitudinal prospective study of the impact of intrauterine substance exposure on long-term outcome. The Stanford-Binet Intelligence Scale: Fourth Edition(SBIS) was administered by examiners blinded to the exposure background of the children, and a pediatrician performed a complete medical evaluation on all the children. The children's primary caregiver completed the Achenbach Child Behavior Checklist. Stepwise multiple regression procedures were used to determine the factors that best predicted 3-year growth, intelligence, and behavior. Groups 1 and 2 differed from Group 3 on head circumference. Group 1 scored lower than Group 3 on SBIS Verbal Reasoning. Group 2 scored Slower than Group 3 on SBIS Abstract/Visual Reasoning. Cocaine exposure predicted poor verbal reasoning. Marijuana exposure predicted poor abstract/visual reasoning. Examiner rating predicted intellectual outcome and caregiver ratings. Caregivers rated exposed children as more aggressive than nonexposed. Contrary to information in the popular media, not all substance-exposed children suffer the same poor prognosis. In fact, generalizations about the fate of drug-exposed children must await additional research into the outcome of the broader population of drug-exposed children, examining the roles of maternal and environmental factors across a variety of geographic locations and socioeconomic levels.